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EDITORIAL
Year : 2015  |  Volume : 141  |  Issue : 1  |  Page : 1-4

World Leprosy Day 2015: Renewing commitment for a leprosy free world!


Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India

Date of Web Publication2-Apr-2015

Correspondence Address:
Bhushan Kumar
Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5916.154476

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How to cite this article:
Kumar B. World Leprosy Day 2015: Renewing commitment for a leprosy free world!. Indian J Med Res 2015;141:1-4

How to cite this URL:
Kumar B. World Leprosy Day 2015: Renewing commitment for a leprosy free world!. Indian J Med Res [serial online] 2015 [cited 2019 Jun 18];141:1-4. Available from: http://www.ijmr.org.in/text.asp?2015/141/1/1/154476

"Leprosy work is not merely medical relief but it is transforming the frustration of life into joy of dedication and personal ambition into selfless services"

-Mahatma Gandhi


Leprosy control programme has been truly a success story worldwide but the last stone is yet unturned. The global registered prevalence of leprosy at the end of first quarter of 2014 was estimated as 0.32 per 10000 population [1] . During 2013, a total of 215656 new cases were reported from 103 countries showing a decline of 17201 cases as compared to the previous year. Though global leprosy programmes made substantial progress in reducing the disease burden, new case detection had plateaued in the range of 215000-245000 worldwide between 2009 and 2013 [1] . In 2013, 13289 new cases had a grade 2 disability (G2D), which reflected low awareness in the community about leprosy and sub-optimal capacity of health systems to detect the disease early. About 9 per cent of the new cases were in children, which also indicated continued transmission of the disease. This may also imply that there has been a degree of stagnation and lack of new approaches in leprosy control. South-East Asia region (SEAR) currently has highest prevalence of 116396 (0.63) cases and highest new case detection rate of 8.38 per 1,00,000 (155385 cases with 72% of the global leprosy burden). India alone accounted for 58.85 per cent of the global leprosy burden [1] .


   Indian scenario Top


A total of 127000 new cases were detected during 2013-2014. Annual new case detection rate (ANCDR) was 9.98 per 100,000 population which decreased marginally from 10.78 in 2012-2013. A total of 86000 cases were on record as on April 1, 2014, giving a prevalence rate (PR) of 0.68 per 10,000 population [2] . There were 51.48 per cent multibacillary cases, 36.91 per cent females, 9.49 per cent children and 4.14 per cent had G2D. Thirty three States/ UTs have achieved the level of elimination, i.e. PR less than one case per 10,000 population, however, some areas still form pockets of high endemicity [2] . Integration of primary leprosy services into existing general health services has made treatment of the disease more easily accessible and helped to reduce the stigma to a great deal.


   Present & future strategies Top


To decrease the disease burden, the WHO has adopted Enhanced Global Strategy (2011-2015) which includes reducing the number of new cases presenting with disabilities through early detection, improving management of acute and chronic complications rehabilitating those with disabilities and fighting stigma and discrimination [3] . The WHO Global Target aims at 35 per cent reduction in the rate of new G2D cases per 100000 population by the end of 2015, compared to baseline (at the end of 2010) and to reduce the burden to one new G2D case per one million population by 2020 [4] . The "Final Push" strategy for elimination is to expand multi drug therapy (MDT) services to all health facilities, encouraging regular and complete treatment, promoting awareness, set time bound targets and good record keeping to monitor the progress towards elimination [5] .

International Federation of Anti-Leprosy Associations (ILEP), an international federation of autonomous non-government anti-leprosy organizations is also working in close co-operation with the national programmes, WHO and other stakeholders including persons affected by leprosy towards above goals [6] .

National Leprosy Programme (India)

National Leprosy Eradication Programme (NLEP) was launched in 1983 covering districts in a phased manner and the whole country was covered only by 1996. The final phase of this fight against leprosy is as critical as the earlier phases. Targets under Programme Implementation Plan (PIP) for 12 th Plan Period (2012-2013 to 2016-2017) have been defined [7] .

Issues that need to be addressed

Problems with leprosy integration: As a part of the global strategy, leprosy services have been integrated with the general health system. Leprosy cases are noted to be sometimes wrongly diagnosed or missed by the primary health centre (PHC) medical officers [8] . This is mainly because of lack of effective training and varied presentations of the disease. Leprosy is a great mimic and confuses at times even the experienced leprologist. Strengthening referral networks is important to support integrated leprosy control services. It is well realized that even after elimination target has been achieved, new leprosy cases will keep coming for at least some years as some level of disease transmission is still continuing or subclinical cases will manifest disease [9] .

Histoid leprosy - a challenge to elimination: Wade first described histoid leprosy in 1963 [10] . In India, new cases of histoid leprosy are still documented with the same incidence rate [10] . These cases are often difficult to diagnose at peripheral level and recently large case series are being reported from various parts of India. As the bacillary load is very high in these patients, they can become a potential reservoir of infection in the community especially in the post-leprosy elimination era with inadequate leprosy expertise [11] .

Quality management of reactions and deformities in post-elimination era: Leprosy is not presently feared so much for its infectivity but rather for the unsightly deformities it can lead to. During 2013-2014, the G2D rate of 4.13/ million population was recorded in India which has increased from previous year (2012-2013) figure of 3.72 / million population [2],[12] . The possible underlying reasons could be dimnishing quality care and incomplete coverage of population by leprosy control activities. Doctors/health workers at PHC level are sometimes unable to detect silent neuritis, atypical presnentations, reactions at early stage, and find difficulty in managing steroid resistant chronic and recurrent erythema nodosum leprosum cases [13] . Stigma at their place of origin and fear of detection by the authorities in case of illegal immigrants are other important factors for patients not reporting to government hospitals for appropriate management [13] .

Decline in number of leprosy experts: Over the last few years involvement of dermatologists in vertical programme has diminished in India and moreover, dermatologists are also now more focused towards lucrative branches of dermatology. Services of dermatologists are essential for making better policies, search of newer drugs, developing the training modules and teaching leprosy management skills to health workers and new generation of medical students [14] .

Drug resistance: The emergence of drug resistance is a cause for concern and a threat in post-elimination era. It is important to monitor the emergence of rifampicin-resistant mutants as it is an important bactericidal component in MDT. Poverty, fear of losing their daily wages, limited job opportunities coupled with difficulties encountered to sustain day-to-day life results in migration of patients back to their home towns abandoning treatment midway. This leads to poor treatment compliance, high drop-out rates, rising defaulter rates and possible emergence of drug resistance. It is essential to monitor drug sensitivity patterns and to accomplish this, the WHO has adopted a network for global surveillance of drug resistance [15] .

Chemoprophylaxis & immunoprophylaxis: An expert group meeting organized by the Novartis Foundation in January 2014 at Zurich, Switzerland, concluded that chemoprophylaxis with single-dose rifampicin (SDR) was efficacious in reducing the risk of developing leprosy, although the protective effect appeared to be smaller in close contacts than distant contacts [16] . Therefore, blanket approach may be more appropriate in endemic areas. Further research is needed to determine the effect of chemoprophylaxis with repeat doses of rifampicin, other regimens (e.g. rifapentine or ROM), or in combination with BCG immunoprophylaxis. Also the duration of long prophylactic treatment and the specific biomarkers that can differentiate infected (asymptomatic) contacts from non-infected contacts need to be evaluated [16] .

Findings from multi-arm vaccine trial in south India showed the overall protective efficacy to be 67 per cent for BCG + killed Mycobacterium leprae, 51 per cent for Indian Cancer Research Centre (ICRC), 41 per cent for M. w. and 22 per cent for BCG alone [17] . Though these vaccines provide some degree of protection against leprosy, but there is no clarity regarding the ideal target population. Also there is lack of adequate clinical trials because of long and variable incubation periods of the disease. Subunit vaccines and peptide synthesized using recombinant DNA technology may prove more efficacious with less side effects as the epitopes used in these vaccines are much purer. But these vaccines are still under investigation [18] .


   Recent advances Top


Ultrasound and MRI are recently being used worldwide to detect the structural changes in peripheral nerves. Unlike MRI, ultrasound is cheap, easily available, less time consuming and can be easily used to follow peripheral nerve along its superficial course. It is useful to detect cases of pure neuritic leprosy, silent neuritis, impending nerve damage during acute reactions and nerve abscess. This non invasive technique may act as a cost-effective tool in early diagnosis of disease as well as reaction [19] .

PCR and reverse transcription-PCR-based techniques have specificity of 100 per cent and a sensitivity of 34 to 80 per cent in paucibacillary patients and greater than 90 per cent in multibacillary patients [20] . Therefore, PCR can provide an excellent adjunct to clinical and histopathological diagnosis of leprosy. PCR coupled with mutation detection analyses rapidly detects drug susceptibility and resistance patterns. Studies have shown that PARK2/PACRG gene located on chromosome 6q25-q27 is associated with overall susceptibility of human populations to M. leprae. Also, NRAMP1 located on chromosome 2q35 may be associated with different leprosy types in some populations. Molecular techniques in future can help in rapid case detection even before the appearance of clinical signs and symptoms [20] .

Among the various cytokines, C-X-C motif chemokine 10 (CXCL10) and interleukin (IL) 6 are elevated during type 1 reaction, while IL7 and Platelet derived growth factor BB chain (PDGF-BB) represent potential markers of Type 2 reaction (T2R). These cytokines may be useful in early diagnosis of reaction and monitoring response to treatment, but their sensitivity and specificity need to be determined [21] .


   Future challenges Top


Consolidation of the gains achieved is the immediate need of the hour [22] . Screening tools need to be developed to detect sub-clinical infection and to decrease the delay between diagnosis and treatment. Predicting leprosy reactions, their early detection and adequate management will change the perception about the disease morbidity and its potential to produce deformities. Diagnosing and managing a relapse is still a challenge. Drug resistance is a serious potential threat to conquer this disease [22] .


   Sustaining the commitment Top


After achieving the target of elimination at all levels, the emphasis now must shift on to sustaining the quality of services. Support from all partners is of utmost importance to ensure that leprosy remains on the health agenda as long as it is necessary. Government, non-governmental organizations (NGOs) and private organizations need to work together in a coordinated fashion in the final battle against leprosy [23] . Continued training of medical officers, nurses, physiotherapists, paramedical workers about quality diagnosis and treatment of leprosy is necessary [24],[25] .


   Rehabilitation Top


Empathy rather than sympathy is important in leprosy rehabilitation. Physical rehabilitation includes physiotherapy, occupational therapy and various reconstructive surgeries to improve the function of the hands, feet and eyes. Social and economic rehabilitation is equally important to restore dignity of leprosy patients [26] . disability prevention and medical rehabilitation (DPMR) services, training in self-care (skin care, wound care and joint care), provision of necessary protective equipment, orthotic appliances, physiotherapy, mobility aid and reconstructive surgery are very crucial in post-elimination era to make the patient self-sufficient and to further reduce the stigma [23] .

Leprosy is one of the most ancient and dreadful diseases. The stigma associated with the disease is an important hurdle in self-reporting. A new environment free of stigma and fear needs to be created for early diagnosis and treatment of the remaining cases towards a leprosy free world.

"The biggest disease today is not leprosy or tuberculosis, but rather the feeling of being unwanted."

- Mother Teresa



 
   References Top

1.
Global leprosy update, 2013; reducing disease burden. Wkly Epidemiol Rec 2014; 89 : 389-400.  Back to cited text no. 1
    
2.
National Leprosy Eradication Programme (NLEP) - Progress Report for the year 2013-14. Available from: http://nlep.nic.in/pdf/Progress%20report%2031st%20March%202013-14.pdf, accessed on December 16, 2014.  Back to cited text no. 2
    
3.
Enhanced Global Strategy for further reducing the disease burden due to leprosy (2011-2015). Available from: thhttp://www.searo.who.int/entity/global_leprosy_programme/documents/ enhanced_global_strategy_2011_2015...._operational_guidelines. pdf, accessed on December 16, 2014.  Back to cited text no. 3
    
4.
The WHO Global Target. Available from: http://www.searo.who.int/entity/global_leprosy_programme/global_target/e/, accessed on December 16, 2014.  Back to cited text no. 4
    
5.
The "Final Push" strategy for elimination. Available from: http://www.who.int/lep/strategy/en/, accessed on December 16, 2014.  Back to cited text no. 5
    
6.
The International Federation of Anti-Leprosy Associations (ILEP) in India. Draft Annual Country Report 2013. Available from: http://www.ilep.org.uk/ilep-co-ordination/countryregional-reports, accessed on December 16, 2014.   Back to cited text no. 6
    
7.
Programme Implementation Plan (PIP) for 12 th Plan Period (2012-13 to 2016-17). Central Leprosy Divison. Directorate General of Health Services Ministry of Health & Family Welfare Government of India. Available from: thhttp://nlep.nic.in/pdf/Final%20PIP,on%203%20May%202013.pdf, accessed on December 16, 2014.  Back to cited text no. 7
    
8.
Sachdeva S, Sood AK. Leprosy Elimination Monitoring (LEM) in India: a novel exercise of monitoring, learning, and capacity building. Indian J Community Med 2014; 39 : 59-62.  Back to cited text no. 8
    
9.
Pandey A. Role of dermatologist in leprosy elimination and post-elimination era. Lepr Rev 2007; 78 : 26-9.  Back to cited text no. 9
    
10.
Mendiratta V, Jain A, Chander R, Khan A, Barara M. A nine-year clinico-epidemiological study of Histoid Hansen in India. J Infect Dev Ctries 2011; 5 : 128-31.  Back to cited text no. 10
    
11.
Palit A, Inamadar AC. Histoid leprosy as reservoir of the disease; a challenge to leprosy elimination. Lepr Rev 2007; 78 : 47-9.  Back to cited text no. 11
    
12.
National Leprosy Eradication Programme (NLEP) - Progress Report for the year 2012-13. Available from: thhttp://nlep.nic.in/pdf/Progress%20report%2031st%20March%202012-13.pdf, accessed on December 16, 2014.  Back to cited text no. 12
    
13.
Husain S. An attempt towards prevention and management of disabilities and deformities in leprosy. Indian J Lepr 2011; 83 : 9-14.  Back to cited text no. 13
    
14.
Athreya SP. Role of dermatologist in post-leprosy elimination era. Lepr Rev 2007; 78 : 40.  Back to cited text no. 14
    
15.
Global Leprosy Programme. Drug resistance in leprosy. Available from: http://www.searo.who.int/entity/global_leprosy_programme/topics/drug_resistance/en/, accessed on December 16, 2014.  Back to cited text no. 15
    
16.
Smith WC, Aerts A. Role of contact tracing and prevention strategies in the interruption of leprosy transmission. Lepr Rev 2014; 85 : 2-17.  Back to cited text no. 16
    
17.
Sehgal VN, Sardana K. Immunoprophylaxis of leprosy: Current status and future prospects. Indian J Dermatol Venereol Leprol 2007; 73 : 71-2.  Back to cited text no. 17
    
18.
Britton WJ, Martin E, Kamath AT, Neupane KD, Roche PW. Immunoprophylaxis against Mycobacterium leprae infection with subunit vaccines. Lepr Rev 2000; 71 : S176-81.   Back to cited text no. 18
    
19.
Rao PN, Jain S. Newer management options in leprosy. Indian J Dermatol 2013; 58 : 6-11.  Back to cited text no. 19
    
20.
Scollard DM, Adams LB, Gillis TP, Krahenbuhl JL, Truman RW, Williams DL. The continuing challenges of leprosy. Clin Microbiol Rev 2006; 19 : 338-81.  Back to cited text no. 20
    
21.
Stefani MM, Guerra JG, Sousa AL, Costa MB, Oliveira ML, Martelli CT, et al. Potential plasma markers of Type 1 and Type 2 leprosy reactions: a preliminary report. BMC Infect Dis 2009; 9 : 75.  Back to cited text no. 21
    
22.
Singal A, Sonthalia S. Leprosy in post-elimination era in India: Difficult journey ahead. Indian J Dermatol 2013; 58 : 443-6.   Back to cited text no. 22
    
23.
Sukumar GM, Shivaraj N, Dayananada M. Proportion, pattern and need assessment of deformities among registered leprosy affected individuals in Chamrajanagar district. Indian J Community Med 2010; 35 : 347-9.  Back to cited text no. 23
    
24.
Ganapati R, Pai VV, Rao R. Dermatologist's role in leprosy elimination/post-elimination. Lepr Rev 2007; 78 : 30-3.  Back to cited text no. 24
    
25.
Sharma NL. Role of dermatologists in leprosy elimination and post elimination era. Lepr Rev 2007; 78 : 54-5.  Back to cited text no. 25
    
26.
Rehabilitation. The International Federation of Anti-Leprosy Association (ILEP). Available from: http://www.ilep.org.uk/facts-about-leprosy/rehabilitation/, accessed on December 16, 2014.  Back to cited text no. 26
    



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